Artisan Contractor Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

* Last Name

* First Name

Business Name

Street Address

City

State

Zip Code

Phone Number

Alternate Telephone

Fax Number

* Email Address

Underwriting Information

Number of owners

Number of Employees

Payroll of Owners

Payroll of Employees

Total annual gross receipts

Total annual sub costs

What is your classification?

Contractors License Number

License Type

Years of experience

Years operated under current name

Other business names

Yes

No

Have you been involved in the original construction or remodeling of town homes, condos, row homes or developments of 15 or more unattached single family dwellings during the past 5 years?

Yes

No

Do you construct footings or foundations which may support dwellings or other structures?

Yes

No

Do you construct slab or monolithic floors?

Yes

No

Do you construct piers or underpinning which may support dwellings or other structures?

Yes

No

Do you construct retaining walls which may support dwellings or other structures?

Yes

No

Do you construct fireplaces or chimneys?

Yes

No

What is the percentage of work done as a General Contractor?

What is the percentage of work done as a Sub-Contractor?

What is the percentage of work done on Residential?

What is the percentage of work done on Commercial?

What is the percentage of work done for Remodeling?

What is the percentage of work done for Renovation?

What is the percentage of work done for Repair or Maintenance?

Claims Information

Were there any losses or claims in the last 5 years?

Yes

No

If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information

Current Insurance Company

How much are you paying now?

What is the liability limit requested?

What is the loss of income requested?

Questions or Comments

Best Time To Contact You

Please let us know the best time to call and discuss your quote.

Morning

Afternoon

Evening

Anytime

Or Specify Other:

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